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Original research article
Sex differences in left ventricular remodelling, myocardial fibrosis and mortality after aortic valve replacement
  1. Anvesha Singh1,
  2. Tarique Al Musa2,
  3. Thomas A Treibel3,
  4. Vassiliou S Vassiliou4,5,
  5. Gabriella Captur3,
  6. Calvin Chin6,
  7. Laura E Dobson2,
  8. Silvia Pica3,
  9. Margaret Loudon7,
  10. Tamir Malley4,
  11. Marzia Rigolli7,
  12. James Robert John Foley2,
  13. Petra Bijsterveld2,
  14. Graham R Law8,
  15. Marc Richard Dweck9,
  16. Saul G Myerson7,
  17. Sanjay K Prasad10,
  18. James C Moon3,
  19. John P Greenwood2,
  20. Gerry P McCann1
  1. 1 Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
  2. 2 Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  3. 3 Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
  4. 4 Cardiovascular Sciences, Imperial College London, Royal Brompton Hospital, London, UK
  5. 5 University of East Anglia and Norfolk and Norwich University Hospitals, Norwich, Norfolk, United Kingdom
  6. 6 Cardiovascular Medicine, National Heart Center Singapore, Singapore, Singapore
  7. 7 Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
  8. 8 Medical Statistics, School of Health and Social Care, University of Lincoln and Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Lincoln and Leeds, UK
  9. 9 Cardiovascular Sciences, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
  10. 10 Cardiology, Royal Brompton Hospital, London, UK
  1. Correspondence to Dr Marc Richard Dweck, Cardiovascular Sciences, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH8 9YL, UK; marcdweck{at}


Objectives To investigate sex differences in left ventricular remodelling and outcome in patients undergoing surgical or transcatheter aortic valve replacement (SAVR/TAVR).

Methods In this multicentre, observational, outcome study with imaging core-lab analysis, patients with severe aortic stenosis (AS) listed for intervention at one of six UK centres were prospectively recruited and underwent cardiovascular magnetic resonance imaging. The primary endpoint was all-cause mortality and secondary endpoint was cardiovascular mortality.

Results 674 patients (425 men, 249 women, age 75±14 years) were included: 399 SAVR, 275 TAVR. Women were older, had higher surgical risk scores and underwent TAVR more frequently (53% vs 33.6%, p<0.001). More men had bicuspid aortic valves (BAVs) (26.7% vs 14.9%, p<0.001) and demonstrated more advanced remodelling than women. During a median follow-up of 3.6 years, 145 (21.5%) patients died, with no significant sex difference in all-cause mortality (23.3% vs 20.5%, p=0.114), but higher cardiovascular mortality in women (13.7% vs 8.5%, p=0.012). There were no significant sex-related differences in outcome in the SAVR or TAVR subgroups, or after excluding those with BAV. Factors independently associated with all-cause mortality were age, left ventricular ejection fraction (LVEF), BAV (better) and myocardial fibrosis detected with late gadolinium enhancement (LGE) in men, and age, LVEF and LGE in women. Age and LGE were independently associated with cardiovascular mortality in both sexes.

Conclusions Men demonstrate more advanced remodelling in response to a similar severity of AS. The higher cardiovascular mortality observed in women following AVR is accounted for by women having less BAV and higher risk scores resulting in more TAVR. LGE is associated with a worse prognosis in both sexes.

  • aortic stenosis
  • AVR
  • CMR

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  • Correction notice Since this article was first published online, the middle initial P has been added to the author John Greenwood.

  • Contributors We confirm that all authors have made significant contribution to this work and have approved the manuscript.

  • Funding This study was in part supported by the British Heart Foundation (University of Leeds, Greenwood JP [PG/11/126/29321]; University of Leicester, McCann GP [PG/07/068/2334]; University of Oxford, Myerson SG [FS/10/015/28104]; University of Edinburgh, Dweck MR [FS/10/026]; University College London, Moon JC [FS/08/028/24767]), the National Institute for Health Research (University of Leicester, McCann PDF 2011-04-51; University College London, Treibel TA [DRF-2013-06-102]), including via its Biomedical Research Centre and Clinical Research Facility programmes, as well as Rosetrees Trust. The views expressed are those of the author(s) and not necessarily those of the UK National Health Service, National Institute for Health Research or Department of Health.

  • Competing interests None declared.

  • Patient consent for publication All patients gave written informed consent.

  • Ethics approval The study was approved by the UK National Research Ethics Service (13/NW/0832), conformed to the principles of the Helsinki Declaration.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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